Transvenous (Laser) RV Lead Extraction

Have a faulty RV lead, that needs fixing, ugh.  Hoping to hear from others who have had this done. 

I am a 72 YO female, basically in good health, with 1st PM implanted in 2011 (dual-chamber St. Jude's), and now #2 PM (from 2018 - Boston Medical - Accolade DR L301, with original St. J leads).

Options are challenging due to:

1) existing subclavian vein stenosis at original site (due to scar tissue; procedure to open it up failed and now collateral veins have developed to take over) so adding a new RV lead that way isn't possible;

2) current PM is on right side of chest, so adding a lead on left side would mean crossing under skin over chest bone. Due to thin anatomy, EP/I don't think that's a good option;

3) implant new PM/leads on other/left side, but EP/I am concerned that stenosis could possibly occur on that side as well. 

SO.... current thinking is to go in and remove existing leads (both) via laser procedure by a specialist, then implant all new on same R side.  One future advantage to 2 new leads is that current leads are not MRI compatible.

Referral into specialist at Wake Forest (NC) and waiting to hear.

Any input/thoughts would be appreciated.  Thanks!


10 Comments

Laser Lead Extraction

by Julros - 2024-03-01 13:59:42

Hi Aulee,

I had an RV lead extracted 18 months ago, so that an ICD coil could be placed.  My subclavian was stenosed as well, with visible colateral veins. My PM and wires had been in place about 3 years. We did discuss the same options you wrote about. They were ready to use a laser if needed, but they were able to extract it using a cutting catheter. They were fully prepared for any contingency, including having a cardiovascular surgeon in the room, and femoral lines placed just in case. There was a room full of people, for sure. I'm told the procedure went smoothly, and I went home that evening. My doctor was a highly experienced EP who specializes in lead extraction, and the hospital is at a major teaching university. 

My recovery was easier than my initai PM implantation, with less swelling and pain, and much faster recovery. 

Best wishes!

colateral veins

by Good Dog - 2024-03-01 17:11:18

I assume that you had a venogram? I am wondering that, because I had the same problem; my vein carrying my leads was closed. However, my doc asked for a second venogram immediately following the first. He wanted to determine if that colateral vein was open and could provide access to the RA. Well, they discovered that it was and it will preclude the need for an extraction of a 30 year old lead. 

I am guessing that they may have already explored that option, but it may be something you could inquire about. Your leads are not that old and extraction is not likely as difficult as it would be in my case. Also, as you indicated, there are advantages to getting a whole new system.

I wish you the very best!

Sincerely,

Dave

RV Lead Issue

by Aulee - 2024-03-02 19:31:40

Thank you both Julros & Good Dog for those most helpful comments!  I am so impressed with the thoughtful feedback from members like you on this sight.  I still have much to learn/understand about the workings of the heart and medical devices.

Good Dog - yes, I had a venogram a while ago but the idea of going through the collateral vein hasn't been discussed--good suggestion!  Will add to my list for discussion with specialist.  One good thing about possibly replacing both old leads is that they are not MRI compatible whereas new ones would be should needing an MRI in the future become important. But, I understand it's a much more involved procedure.

Thank you both again!

~ Aulee

Extraction Problem

by Figallegro - 2024-03-03 21:09:05

I don't knoiw all the medical terminilogy details of my recent lead extraction as others have stated above, but  I ended up with severe trricuspid valve regurgitation due to damage to two leafs of my tricuspid valve. One of the leads was originally led through the valve which I learned is common. Both leads were inserted in 2016 and developed fractures and needed to be replaced. During laser removal, both leads broke and neeeded additional process to grab and remove them.  Seeing three different highly credentialed surgeons over the next two weeks for opinion of best way to proceed, either repair or non-invasive replacement..Surgeon that did the extraction was very qualified with many years experience.

Not sure if you have tricuspoid valve involvement in the process, but sharing this as a precaution of you will have removal. As a side note, no one I have talked with in the cardiothorasic area has ever seen this happen before during removal. 

 

options

by Tracey_E - 2024-03-04 13:37:08

The ep that does the extraction should be able to evaluate your veins and leads to determine how risky it is to extract, if the veins are up to it and if the leads are likely to come out without falling apart. Your leads are old but not excessively so. I'm facing this same decision- very old lead starting to go bad and no room for more. My preference is to extract so I'll have MRI-compatible hardware and just to not have a chest full of wires.

If it's too risky to extract, we are discussing leadless. They have just in the last year started giving them to patients with existing leads so it's new and mostly untried, however I'm hopeful they'll consider me a candiate if they decide extraction is too risky. You might want to ask if it's an option for you. Leadless devices have been around for a few years now, it's just using them on patients with existing leads that is new. Also, using them for dual chamber pacing is new. 

Wake Forest (my alma mater!) is very good, but Duke is cutting edge on extraction. Just food for thought as a second opinion if they decide extraction is the way to go, or are willing to consider leadless. 

Self Advocate

by Figallegro - 2024-03-04 18:22:15

Tracey;  Thank you for your post. My reason for posting about lead extraction problem was to bring attention to being aware of potential risks. No doctors mentioned the possibioilty of wireless leads nor lead breakage during extraction and I am glad additional ibnformation is being presented. My lead extration was done at a center of excellence with an excellent EP, but now I see I needed to be a better advocate for myself.

Figallegro

by Tracey_E - 2024-03-04 19:12:12

Ten years ago extraction was considered high risk. Now, the technology has come a long way and there are a lot more experienced surgeons, so it's no longer considered high risk, but it IS still a serious surgery and not without risk. It's always important to be informed. 

RV Lead Issue, cont'd.

by Aulee - 2024-03-05 18:30:28

Thank you Figallegro and Tracey.  More excellent tips/comments as I go down this path. Will help with my list of questions for specialist.  

 

closed vein for leads

by islandgirl - 2024-03-06 22:04:10

I had a 3rd lead placed a couple of years ago.  They had done some kind of test that showed my vein was open when I was in pre-op.  When I went in and was given general anaesthesia, they found the vein was blocked and had formed collateral veins.  When I woke up they told me they had to tunnel across my chest and place the lead in the vein on the other side.  The tunnelling recovery was very painful.  The lead across my chest is not as promient as it was the first year.  Last year I had the device repositioned and replaced and the cardiothoracic surgeon said he could have opened up that blocked vein instead of tunnelling across the upper chest.  He said when my device needs replacing, and he's also watching my leads, he would change the routing.  

Blocked vein for leads

by Aulee - 2024-03-07 09:46:30

Thanks Islandgirl for that input.  Definitely plan to probe further into possibilities re: my current blocked subclavian vein as we consider options for add'l lead or extraction/replacement.  Your comment nudges me even more to getting a 2nd opinion with specialist (waiting for 1st opinion appt!).  Hope you are doing well.  Thanks again.

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